Spotlight on Quality: Improving Collaboration to Manage Dose
On September 1, 2011, the Joint Commission issued a Sentinel Event Alert related to radiation dose from diagnostic imaging. “If a patient receives repeated doses, harm can occur as the cumulative effect of those multiple doses over time,” the alert states. “Conversely, using insufficient radiation may increase the risk of misdiagnosis, delayed treatment, or . . . repeat testing with the attendant exposure to even more radiation.”¹ Though the radiology community has been aggressive in its efforts to educate the population about the relative exposure associated with medical imaging, high-profile dose incidents such as those at Cedars-Sinai Medical Center (Los Angeles, California) represent cause for continued concern and diligence for hospitals. Teri Yates, chief compliance officer and director of quality management for Radisphere (Beachwood, Ohio), says, “There is an opportunity for better management of radiation dose through effective collaboration between radiologists and hospitals. Unfortunately, many radiology groups don’t have the dedicated resources to work on quality projects like this—their clinicians are busy reading cases and taking care of individual patients. That’s the gap we want to fill.” For this reason, Radisphere recently launched a new initiative, The Final Read on Quality, aimed at supporting community hospitals’ efforts to improve quality in imaging—beginning with minimizing radiation dose. “What inspired the initiative is the need to ensure that radiologists and department staff are effectively partnering on issues of quality,” Yates says. Dose Reduction Radisphere is currently developing a set of CT-exam protocols aimed at helping its hospital clients reduce radiation dose, and it is planning to release them at the end of November. “We’re working with our physicians to develop specific, written criteria on how to modify protocols for vulnerable patients, such as children and pregnant women,” Yates says. “Those guidelines will specifically advise the technologist on how to reduce the dose, as appropriate, for each individual patient.” Yates adds, however, that direct protocol optimization only represents a piece of the overall dose-reduction puzzle. “To implement a really effective dose-reduction program, you need to educate patients about the issue so that they’re aware of the potential risks. You also need to educate members of hospital medical staff so that, when appropriate, they consider lower-radiation exams or modalities with no radiation, such as ultrasound or MRI,” she says. To enhance these educational efforts, Radisphere’s new quality initiative hinges on physician-to-physician communication, Yates says. “In most instances, we have a radiologist physically present at the hospital, and that person is in the best position to assist because he or she already has a relationship with the medical staff,” Yates notes. “Physician conversations about quality are very effective.” In addition, if radiologists see a case where they feel dose could have been further reduced, or a different study would have been more appropriate, they will refer that back to Radisphere’s quality department as an education opportunity for the hospital. “It’s truly a team effort,” Yates notes. Future Initiatives In the future, The Final Read on Quality initiative will touch on a number of other quality and safety issues related to radiology, including critical-results reporting, the prevention of wrong-site/wrong-patient/wrong-procedure incidents, and the prevention of adverse effects from iodinated contrast media. “Critical-results reporting for outpatients still has a lot of room for improvement,” Yates observes. She notes that while inpatient and emergency-department physicians are generally easy for radiologists to reach with critical results, locating a referring physician with an unexpected but critical finding on an outpatient study is another challenge. “We’ll be working with our hospitals to develop specific escalation procedures so that if there is a critical finding, and there is difficulty contacting the referring physician, the next step has been established,” she says. “Every hospital has to define its own plan, and we’ll help it measure how long these communications are taking and identify opportunities for improvement by analyzing outlier cases.” In addition, Radisphere is exploring new media for results communication. Yates says, “We are looking for more innovative ways to deliver those results, beyond just picking up the phone and making a call.” Another issue that Radisphere wants to help address is that of wrong-site/wrong-patient/wrong-procedure incidents. Radisphere will work with hospitals to implement a slightly adapted version of the universal protocol used in operating rooms: preprocedure verification, marking of the procedure site or region of interest (when possible), and final preprocedure double-checking. “This is something we see as a significant area of opportunity for improved safety,” Yates says. “We’ll work with our hospitals and radiologists to determine what the checklist should be and to define the type of final review that should take place before initiation of the imaging procedure.” Radisphere also will develop recommendations for educating clinicians and screening patients to minimize the risk of an adverse incident relating to acute kidney injury from iodinated contrast media. This issue relates directly to the stated concerns of CMS. “CMS proposed adding this to the list of nonreimbursable hospital-acquired conditions for 2012,” Yates says. “Although CMS concluded that limitations in current coding methodology would make it impractical to designate it as a hospital-acquired condition, it also stipulated that it remains concerned about the issue, and that substantial opportunity exists for hospitals to improve quality in this area. We see a need to educate clinicians about which patients are at the highest risk, to advise them on situations where contrast may not be needed, and to ensure that all patients receiving contrast are adequately hydrated (which means direct counseling with outpatients).” In conclusion, Yates says deepening the communication among radiologists, radiology-department employees, and the hospital’s medical staff is critical to improving imaging quality. “We’re focused on reinforcing that collaborative relationship. That’s what this initiative is all about,” she says. Cat Vasko is editor of and associate editor of Radiology Business Journal.